Specialized services

Although inevitably all forensic psychiatrists have patients under their care with personality disorders there is a wide lack of agreement about the diagnosis and treatability of this group, and in many instances an absence of conviction about the value of treatment. At the time of writing (early 1999) psychopathy and severe personality disorder are popular topics for debate in the United Kingdom, with an emphasis on the problems of management of those classified as having antisocial personality disorder or dissocial personality disorder.

There are few specialized centres for the assessment and treatment of severe personality disorder. The Special Hospitals each have personality disorder units, and the Henderson Hospital in Surrey, an open hospital, claims a substantial degree of success in treating informal patients, some of whom have a past history of Special Hospital admission. The Henderson uses an approach based on a therapeutic community model involving motivated patients. Two more similar units are to be established in other regions of England in the near future. In the Prison Service, Grendon Prison is established as a therapeutic centre using a therapeutic community model for sentenced prisoners. Its history and the evaluation of its work is well documented and a second similar prison is planned in Staffordshire.

Forensic psychotherapy is a growing subspecialty which reflects a new interest in applying psychodynamic principles and other forms of psychological therapy to the treatment of offenders with psychological and psychiatric problems. It has a long history of work with offender patients in the Portman Clinic in London and at Broadmoor under the leadership of the late Dr Murray Cox and at the Henderson Hospital. (1,9)

Learning disability patients in Special Hospitals have been accommodated in Ashworth and Rampton Hospitals, but in recent years only individuals presenting a grave and immediate danger to others have been accepted and there is a continued need to take this group, since care for those with learning disabilities outside Special Hospitals is largely in the community. The large hospitals have been closed. Many, even with mild learning disabilities, who had been admitted in previous decades, have been moved out as strategies for their care have changed. Medium-secure units can manage many of these patients who often also have other psychiatric disorders.

Adolescent forensic psychiatry services have been developed slowly and require staff trained partly in child and adolescent psychiatry and also in forensic psychiatry. The first regional centre in the United Kingdom has been established for some years at Manchester.

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